BENEFICIARY DESIGNATION

POLICY INFORMATION
Name of Policyholder Policy Number Division Number Member/Employee ID

MEMBER/EMPLOYEE INFORMATION (MUST ALWAYS COMPLETE)

Last Name Given Name Initials Date of Birth (dd-mmm-yyyy)

REQUESTOR INFORMATION
Who is requesting a beneficiary change? Member/Employee Spouse (If the spouse is requesting the change please complete the information below) Last Name Given Name Initials Date of Birth (dd-mmm-yyyy)

BENEFICIARY DESIGNATION OR CHANGE OF BENEFICIARY (THE BENEFICIARY INFORMATION YOU PROVIDE WILL APPLY TO ALL LIFE AND AD&D INSURANCE BENEFITS UNDER THE GROUP POLICY)
Beneficiary Last Name Beneficiary Given Name Relationship to the Insured Age % payable to each Type of Desigination

Revocable1 Irrevocable2 Revocable Irrevocable Revocable Irrevocable Revocable Irrevocable

1 2

A revocable beneficiary designation is one that may be changed at any time without consent of the designated beneficiary.

An irrevocable beneficiary designation is one that cannot be changed without the signed consent of the irrevocable beneficiary. If you are designating a irrevocable beneficiary please have them sign below. If the designated beneficiary is estate, please indicate "Estate" under Beneficiary Last Name. No other information is required.

If one of the beneficiary designations types has not been checked off, we will consider your beneficiary to be revocable. In Quebec, the designation of a spouse as beneficiary is irrevocable unless otherwise specified. If you designate an irrevocable beneficiary, you will require a Waiver of Rights to be signed by the irrevocable beneficiary in order to make any future changes. We strongly recommend that you do not name a minor as an irrevocable beneficiary. If you are designating a minor as a beneficiary please complete the Declaration Appointing Trustee on page 2. If you would like to designate a contingent beneficiary, please complete the Contingent Beneficiary Designation on page 2.

AUTHORIZATION
If more than one beneficiary is designated and if one of the beneficiaries dies before the Insured, his/her share will be divided equally among the other designated beneficiaries. In accordance with the terms and conditions of the above-mentioned group insurance policy, I, the undersigned, hereby revoke any previous designation of beneficiary and name the above-mentioned person(s) as my beneficiary entitled to receive any amount payable under this group policy upon my death. If this beneficiary predeceases me and I do not have a contingent beneficiary, the death benefit will be payable to my estate. To the extent permitted by law, I reserve the right to alter or revoke the beneficiary designation. The beneficiary designation stated on this form will supercede all prior dated designations and will apply to all coverage in force under this group policy unless specific instructions to the contrary have been received by Industrial Alliance Insurance and Financial Serivices Inc.

x
Member/Employee Signature (must always sign) Date (dd-mmm-yyyy)

x
Spouse Signature (If form is being completed by the spouse)
Please send your completed form to:

Date (dd-mmm-yyyy)

x
Signature of designated irrevocable beneficiary (must always sign)
FORM 4080 PDF (JUN/2012)

Date (dd-mmm-yyyy)

Special Markets Solutions Industrial Alliance Insurance and Financial Services Inc. 2165 Broadway W, PO Box 5900, Vancouver, BC V6B 5H6 Phone: 1-800-266-5667 Fax: 1-888-553-5433 solutions@inalco.com Page 1 of 2

SUPPLEMENTARY BENEFICIARY DESIGNATION FORM

Complete this page if you are appointing a trustee, contingent beneficiary or changing an irrevocable beneficiary.

DECLARATION APPOINTING TRUSTEE (TO BE COMPLETED IF BENEFICIARY IS A MINOR)

Note: If more space is needed, please attach a separate sheet of paper, dated and signed. If you are naming a beneficiary who is under the age of 18, you should name a Trustee to receive the monies in trust for the beneficiary. Name of Trustee for any Minor Beneficiary:

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Member/Employee Signature (must always sign) Date (dd-mmm-yyyy)

x
Spouse Signature (If form is being completed by the spouse) Date (dd-mmm-yyyy)

CONTINGENT BENEFICIARY DESIGNATION

If all of my primary beneficiaries predecease me, I designate the following individual(s) as my beneficiary(ies). Beneficiary Surname Beneficiary Given Name(s) Relationship to Insured % payable to each

x
Member/Employee Signature (must always sign) Date (dd-mmm-yyyy)

x
Spouse Signature (If form is being completed by the spouse) Date (dd-mmm-yyyy)

WAIVER OF RIGHTS OF IRREVOCABLE BENEFICIARY (MUST BE COMPLETED IF IRREVOCABLE BENEFICIARY WAS PREVIOUSLY DESIGNATED)
For Group Policy Number Member ID Insured Name

By my signature below, I, coverage.

agree to relinquish all my rights as irrevocable beneficiary in the above named insured's group

x
Signature of the irrevocable beneficiary relinquishing rights to group policy proceeds Date (dd-mmm-yyyy)

PLEASE SEND YOUR COMPLETED FORM TO:

Special Markets Solutions Industrial Alliance Insurance and Financial Services Inc. 2165 Broadway W, PO Box 5900, Vancouver, BC V6B 5H6

QUESTIONS?

Contact us toll-free at 1-800-266-5667 Monday to Friday from 6:30 a.m. to 4:30 p.m. PST or by email at solutions@inalco.com

FORM 4080 PDF (JUN/2012)

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